Causes of chronic malnutrition: The cultural dimension

By Bronwen Gillespie

Bronwen has a degree in Anthropology/International Development and a MA in Global Political Economy. She has worked in the area of food security and income generation in rural settings ranging from Armenia to Nicaragua. She is currently concerned with questions of food sovereignty in increasingly globalised world.

Many thanks to Iñigo Lasa, Head of Mission of Action Against Hunger in Peru who contributed all the country situation information, and to Elisa Dominguez, Acción Contra el Hambre - Spain, for coordinating the production of the article.

The fight against chronic malnutrition is now Acción Contra el Hambre (ACH's) focus in Peru, in part because malnutrition rates remain surprisingly high despite the country's economic growth. ACH is also concerned about malnutrition's significant hidden cost to society. One third (33.3%) of children in rural Peru suffer from chronic malnutrition and in Apurimac, the Highlands province where ACH has begun to work, rates rise to 44.3%. Anaemia is estimated to affect a shocking 64.2% of children between 6 and 36 months of age¹. What does this mean? Malnourished children under three years of age experience irreversible stunting and reduced cognitive, social and emotional development, often starting school later or reaching educational goals more slowly than their peers². Malnutrition has an impact on work productivity, the success of the education system, and is a burden on healthcare resources. Every person with malnutrition suffers from an average 10% reduction in their potential earnings during the course of their lives³. Poverty, therefore, is an enduring consequence of malnutrition. It is inaccurate, however, to assume that malnutrition is caused primarily by poverty: "Two of every 3 extremely poor children in Peru are not malnourished. Even without managing to eradicate poverty, there is much that can be done to avoid child malnutrition"⁴. Income growth alone is not enough to reduce levels of child malnutrition, it is necessary to examine the complex issues underlying high rates of malnutrition.

Malnutrition is caused by insufficient dietary intake as well as disease. In Central America, for example, lack of food is not usually the primary cause of child malnutrition but has more to do with dietary and hygienic practices and access to health care⁵. In rural areas of the San Jeronimo district in the Peruvian Andes, 73.9% of women do not finish any formal education, which is considered the most important underlying cause of malnutrition in the area⁶.

Malnutrition is also about culture, identity and the vulnerability of traditional practices in the face of increased participation in a global economy. This statement is not trying to apportion blame for the prevalence of malnutrition on cultural peculiarities; this would move the debate into 'dangerous waters'. However, there are lessons and parallels to be drawn with the industrialised world, where anti-obesity campaigns cannot simply rely on public messages about what to eat. Such a strategy would fail from a lack of attention to the "complex nature of food culture and habits"⁷. The same can be said for interventions that aim to reduce malnutrition. Programmes that do not address beliefs and habits around food consumption will almost certainly have limited impact.

Studies have pointed to the important distinction in Andean cultures between 'cold' foods and 'hot' foods. This has little to do with their actual temperature but refers instead to their intrinsic qualities. Vitamin-rich food is not fed to children if it is deemed to be unsuitably cold or hot⁸. Concepts such as this have to be taken into account when making recommendations about how to improve toddlers' diets. We have also seen that canned tuna doled out by a government food programme is saved for prestigious visitors, rather than fed to children for whom it was donated. The whole social aspect of food sharing makes it unrealistic to expect food donations to be used exactly how they were intended. Often the extra food is provided to the father or main income earner rather than to the children, as he is logically seen to play a more key role in the family's survival strategy.

Researchers have found that membership in certain cultural groups can imply greater malnutrition rates compared to neighbours with other ethnic backgrounds. A study in Guatemala found that "controlling for income and other household and community characteristics, ethnicity remains an important determinant of child nutritional status"⁹. An investigation in the Bolivian Andes concluded that although the level of education of the mother was an important factor, the fact that the mother was Quechua rather than Aimara was also significant for explaining malnutrition, after having taken education levels into account¹⁰. Perhaps the internal equilibrium or logic of food and production systems in these societies has been undermined by external influences, or knowledge is not being shared as successfully over generations.

As traditional lifestyles come into closer interaction with the dominant industrial or modern system, and as indigenous peoples suffer social prejudice, it should not be surprising that consumption behaviour mimics that of dominant classes. In Peru it can be seen that nutrient rich, locally grown traditional foods fall out of favour, compared to more recently available (and easier to prepare) processed foods. For example, quinoa, originating in the Andes and now promoted world-wide as a health food, has only recently regained ground as a crop due to great interest from importing countries such as the United States. Meanwhile, Andean farmers continue to add greater quantities of pasta to their diets and to celebrate with carbonated soft drinks. In part, providing the family with storebought food is a status issue in the rush to appear modern.

A mother feeding her child in the highlands

Changes in diet are also explained by changes in land use. Traditional subsistence systems have been gravely altered by participation in modern systems, as there is a move towards exportoriented production, a reduction in diversity of products grown, and less local control over food distribution. Income gained from crops sold elsewhere is used to buy less nutritious processed food, as less land is available for producing for family consumption. This offers a partial explanation for a general reduction in the caloric intake and diversity of diet¹¹. Export oriented production has been seen to contribute to a decline in family nutrition in Guatemala as men control spending from increased export earnings, rather than their wives who are more likely to use income for immediate family needs. At the same time, women end up having to help in production for export rather than growing staples or carrying out small scale independent economic activities¹². In rural Peru, it is common that families opt to sell rather than consume food necessary for good health. In the Santa María de Chicmo region of Apurimac in Peru, only 10% of families with pregnant women and/or children under 3 years of age eat animal protein once a week¹³. The few animals owned by the family are in many cases their only source of income and families do not have the 'luxury' of consuming animal protein themselves.

Shifts in food culture and lifestyle due to globalisation have lead to a challenging health problem. Obesity and malnutrition are more and more frequently seen in the same communities, even within the same families, as growing rates of stunted children having overweight mothers. This has been observed in Latin America, with the highest obesity rate of 16% occurring in Guatemala¹⁴. This 'nutrition transition', in which a diet based on low calorie plant foods and high activity is being replaced by higher calorie processed foods and a less active lifestyle, is part of a larger change in the economic relations of global production and distribution systems.

A Quechua woman selling varieties of potatoes in a local market

Due attention to the cultural dimensions of food systems is required if our aim is not only to aid malnourished children, but to allow communities to live without the burden of malnutrition as the next generation is born. ACH proposes to help populations in extreme poverty in the Peruvian highlands overcome the burden of malnutrition with an approach that recognises the overarching importance of the social and cultural environment.The work to be carried out in natural resource management, sanitary and hygienic conditions, infant care, improved healthcare services, and attention to nutrition should be informed by an understanding of the particular local vision and practices. ACH aims to create a model or a set of research-based guidelines, tested through experience, for working with cultural awareness in nutrition and aimed at assuring coherence with local traditions related to food systems.

The emphasis on understanding food systems from a cultural point of view is backed up by the conclusions of a CARE programme dedicated to reducing malnutrition with a collaborative community based approach, working in the Ayacucho area of the Peruvian Sierra. As a result of that experience, CARE states that efforts to curtail malnutrition should start with a detailed study regarding food and nutrition culture, as well as paradigms related to knowledge, beliefs, customs, attitudes, behaviour, feelings and experiences that shape eating habits and practices, given that these have a direct impact on family and community decision making¹⁵.

A second aspect of ACH's intervention is aimed at encouraging sustainable change and facilitating local acceptance. This involves a community based methodology in which the actions are locally directed and organised, supported by close contact with professionals inside the existing health system. Personalised aid, negotiation, and dialogue between mothers and trained local volunteers (who are also mothers, ideally) will be focused towards taking action, step by step, rather than relying on more formal information-transfer education models. It will be essential to work towards the creation of an atmosphere of confidence and to include close follow-up, with regular monthly checks on progress and debates about obstacles. The merits of this model have been discussed by World Bank and CARE.

As part of the aim to make a long term impact on rates of malnutrition, the programme will work with community members interested in re-valuing local and traditional food ways. This will help to ensure that healthy and unique consumption patterns are not lost in the face of external influence, while at the same time facilitating resource use that favours environmentally suitable and traditionally diverse agricultural production for local consumption.

The World Health Organisation now recognises that nutrition policy must refer to and address issues around food and not just nutrients16. While the 'medicalisation' of eating has thankfully allowed dietary deficiencies to be characterised and diagnosed, this does not mean that 'treatment' can simply be prescribed without addressing cultural issues around food.

If you have any comments regarding this article, please contact: hom-pe@acf-e.org

¹CIAS (2009). Informe de Avances Objetivos Desarrollo del Milenio, Comité Interministerial de Asuntos Sociales

²World Bank (2009). Promoción del crecimiento para prevenir la desnutrición crónica. p21

³See footnote 2.

⁴Francke, Pedro (2004). Propuestas de reforma de programas nutricionales infantiles en el Perú

⁵World Bank (2009). Promoción del crecimiento para prevenir la desnutrición crónica. p22

⁶Kusi Warma (2009). Propuesta en nutrición, salud, seguridad alimentaria y saneamiento básico en los distritos de San Jerónimo y Santa María de Chicmo.

⁷Gracia Arnaiz, Mabel (2007). 'Comer Bien, comer mal: la medicalizacion del comportamiento alimentario' in Salud Publico de Mexico, Vol. 49, no. 3, p240.

⁸Kuhnlein, H and Pelto, G (1997). Culture, Environment and Food to Prevent Vitamin A Deficiency, INFDC.

⁹Marini, Alessandra and Gragnolati, Michele, (2003). Malnutrition and poverty in Guatemala at http://ideas.repec.org/p/wbk/wbrwps/2967.html

¹⁰Morales, Aguilar and Calzadilla (2004). 'Geography and culture matter for malnutrition in Bolivia' in Economics and Human Biology 2 (2004) 373-389. p383

¹¹Pelto, Gretel and Pelto, Pertti, (1990). 'Dieta y Deslocalizacion: Cambios Dieticos Desde 1750' in Rotberg, R, El Hambre en la Historia. p340-362

¹²Thrupp, Lori Ann, (1995). Bittersweet Harvests for Global Supermarkets: Challenges in Latin America's Agricultural Export Boom, World Resources Institute. p83

¹³UNICEF (2003). Crecimiento y Desarrollo Temprano World Bank (2009). Promoción del crecimiento para prevenir la desnutrición crónica. p18

¹⁴CARE Peru, (2006). Consejeria comunitaria para incorporar hábitos saludables de nutrición en los hogares, Experiencia en Tambillo - Ayacucho

¹⁵Contreras Hernandez, and Gracia Arnaiz, (2004) Alimentación y Cultura. p464